Use drug resistance testing and treatment history to guide antiretroviral therapy in advanced HIV

Advanced HIV disease remains a major global health concern despite substantial progress in antiretroviral therapy (ART). People presenting with or progressing to advanced HIV, defined as a CD4 count < 200 cells/mL, often have diverse and complex antiretroviral drug resistance due to previous ART exposure or inconsistent adherence. This makes selecting effective ART challenging, although various clinical trials have demonstrated potential ART regimens in these patients. Nonetheless, drug resistance testing is essential to guide ART, which should include an active, high-barrier anchor drug (e.g. second-generation integrase inhibitors or boosted protease inhibitors), combined with fully active backbone agents, when available. Emerging ART options include novel drug classes and long-acting formulations; these may help overcome problems such as resistance or adherence, though access and resistance monitoring remain limited in many settings. Further research is needed to optimise outcomes for people living with advanced HIV.